Provider Demographics
NPI:1417603796
Name:THE BALANCED DIETITIAN LLC
Entity type:Organization
Organization Name:THE BALANCED DIETITIAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:MALLORY
Authorized Official - Middle Name:CLARE
Authorized Official - Last Name:STORRS
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, RD, LD
Authorized Official - Phone:708-341-8789
Mailing Address - Street 1:10631 PALOS WEST DR
Mailing Address - Street 2:
Mailing Address - City:PALOS PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60464-1598
Mailing Address - Country:US
Mailing Address - Phone:708-341-8789
Mailing Address - Fax:
Practice Address - Street 1:10631 PALOS WEST DR
Practice Address - Street 2:
Practice Address - City:PALOS PARK
Practice Address - State:IL
Practice Address - Zip Code:60464-1598
Practice Address - Country:US
Practice Address - Phone:708-341-8789
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty